Cochlear Implantation in a Patient with Granulomatosis with Polyangiitis.

BACKGROUND: Granulomatosis with polyangiitis (GPA) otologic manifestations include conductive and sensorineural hearing loss (HL). Vasculitis is assumed to be the primary cause of otologic manifestations. Deaf patients and patients with HL who do not benefit from hearing aids can benefit from cochlear implants (CI). There are currently no specific guidelines for treatment of patients with GPA suited for CI. OBJECTIVES: To assess whether patients who are deaf due to GPA are good candidates for CI and if prior surgical or medical treatment of the inflammation are needed. METHODS: A case report is presented. RESULTS: A 71-year-old female patient with GPA and bilateral profound HL underwent CI. Prior to CI, preparation consisted of audiological evaluations by an otolaryngologist and a rheumatologist, followed by a course of prednisone and methotrexate for middle ear and nasal inflammations. CI was performed with no complications. The speech reception threshold and the monosyllabic word discrimination score after surgery were 25 dBHL and 75%, respectively. CONCLUSIONS: Inflammation due to GPA can be controlled medically with immunosuppressive medications without subtotal petrosectomy, as in chronic suppurative otitis media. Satisfactory audiological results can be expected.

[IMPLANTATION OF A VIBRANT SOUNDBRIDGE IN A WOMAN WITH SENSORINEURAL HEARING LOSS AND RECURRENT OTITIS EXTERNA: A CASE STUDY].

INTRODUCTION: Rehabilitating hearing loss is highly important due to its positive impact on the ability to understand speech, and the related consequences on family, social and work communication abilities. Children with hearing loss have learning difficulties that adversely affect speech and language acquirement. Most patients with hearing loss can use conventional hearing aids that are partially or completely placed in the external ear canal. Middle ear implants are used when conventional hearing aids are not suitable due to medical reasons, mainly diseases of the external ear canal and the tympanic membrane. The external component of the middle ear implant digitally translates the acoustic information (sound waves) to the implanted part, where the digital information is back-translated to mechanical information (vibrations) which vibrates the ossicle to which it is attached. We present a patient who underwent a Vibrant Soundbridge implantation after unsuccessfully using hearing aids due to recurrent otitis externa. The patient's hearing improved significantly. We conclude that middle ear implants can be an effective treatment for patients who cannot use conventional hearing aids.

Blood glucose levels as an adjunct for prehospital field triage.

OBJECTIVE: Elevated blood glucose levels (BGL) are known to be part of the physiologic response to stress following physical trauma. We aimed to study whether a measured BGL might help improve accuracy of field triage. METHODS: We conducted a retrospective study using the Israel Defense Forces Trauma Registry. BGLs were determined upon hospital arrival and were not available to medical providers in the field. RESULTS: There were 706 casualties in the registry who had a recorded BGL upon hospital arrival. Sixty percent (18/30) of casualties who had a BGL ≥200 mg/dL had been triaged in the field as severely wounded, whereas 11% (71/651) of casualties who had a BGL <200 mg/dL had been triaged as severely wounded. For predicting an Injury Severity Score >15, the positive likelihood ratio using field triage of severe was 11, using BGL ≥200 mg/dL was 8, and using a combination of the two tests was 26. For predicting the need for intensive care unit (ICU) admission, the ratios were 8, 13, and 23, respectively. CONCLUSIONS: Elevated BGL improved prediction of high Injury Severity Score and ICU use among casualties triaged as severe. If future research using BGL measured in the field yields similar results, combining BGL with standard field triage may allow for more accurate identification of casualties who need acute field intervention, have major injury, or require ICU admission.

Walking between the drops: Israeli defense forces' fluid resuscitation protocol.

BACKGROUND: Current research in trauma resuscitation indicates that it is important to strike a balance between withholding intravenous fluid therapy, on one hand, and giving too much, on the other. The Israel Defense Forces' former protocol for prehospital fluid administration in the trauma setting was intended to navigate this balancing act. It turned out that the protocol was not being appropriately implemented in field conditions. OBJECTIVES: We describe our process improvement, which resulted in our revised protocol. Our goal in drafting the new protocol was to achieve yet another balance, this time between the recommendations derived from accumulating science, and the efficacy with which they could likely be implemented in the field. DISCUSSION: We review the available research in prehospital fluid administration, and then develop our current protocol. Per our a priori requirements, the protocol is unified in that medical personnel from a very wide spectrum of caregivers can apply it; and it is appropriate for both short evacuation time scenarios (e.g., low-intensity conflicts) and lengthier evacuation scenarios (e.g., high-intensity conflicts). CONCLUSION: Survival is likely improved if guidelines do not add unnecessary complexity and are easily implemented. We believe that the current protocol is suitable for the large majority of trauma patients, and helps guide providers toward a primary decision-point regarding fluid administration. Nonetheless, as long as only coarse clinical parameters for identifying shock are available, and data regarding optimal treatment are conflicting, offering truly balanced fluid resuscitation guidelines is a lot like walking between the drops.

Analysis of the causes of death of casualties in field military setting.

OBJECTIVE: We assessed the causes of death of military casualties in order to determine the characteristics of injury and to determine how survivability can be improved. METHODS: A retrospective review of the trauma registry of the Israel Defense Forces was conducted. The causes of death were determined. Casualties that were found alive but died later at any level of care were included. RESULTS: Information about casualties that was recorded during the years 2002-2009 was reviewed. Eighty-one fatalities were included in the analysis. Fifty-one (63%) fatalities were caused by gunshot wounds. Analysis of the data regarding the cause of death revealed that 66 (81.5%) of the casualties died because of hemorrhage and 25 (30.9%) because of head trauma. Of the casualties that died of hemorrhage, 12 (18.2%) had neck or limbs potentially compressible hemorrhage. All fatalities from hemorrhage died before arriving at a medical facility. CONCLUSION: Torso noncompressible hemorrhage was found to be the main cause of death among the casualties investigated. Potentially compressible hemorrhage and head injury are significant too. Research and development of means to treat hemorrhage and emphasis on distribution of means to stop hemorrhage and on training may improve outcome of potentially compressible hemorrhage.

Training modalities and self-confidence building in performance of life-saving procedures.

OBJECTIVE: Physicians and paramedics in the Israel Defense Forces are trained to perform advanced medical procedures using standardized training modalities, such as manikins. We studied the association of experience using these training modalities with self-reported confidence in procedure performance. METHODS: Providers were sent a questionnaire regarding their experience with and self-confidence levels for performing endotracheal intubation, cricothyroidotomy, needle chest decompression, tube thoracostomy, and intraosseous infusion. RESULTS: Provider level (physician or paramedic) and gender were associated with reported self-confidence levels. Manikin and supervised and unsupervised patient experience exhibited positive associations with self-confidence, but (animal) model experience did not. For many procedure-training modality pairs, we identified a plateau level above which additional experience was minimally associated with an increase in self-confidence. CONCLUSIONS: Among military advanced life support providers, self-confidence levels in procedure performance are positively associated with experience gained from manikins and supervised and unsupervised patient application. We were not able to demonstrate a clear benefit of an animal model in increasing self-confidence. A plateau was generally identified, indicating decreased benefit from the use of a particular training modality for a particular procedure. Modifying training regimens in light of these findings may help maximize the self-confidence of advanced life support providers more efficiently.

Triage and air evacuation strategy for mass casualty events: a model based on combat experience.

BACKGROUND: Management of combat casualties should optimize outcomes by appropriate patient triage, prehospital care, and rapid transport to the most capable medical facility, while avoiding overwhelming individual facilities. METHODS: Planning the medical support for the campaign was done by the medical department of the IDF Southern command in cohort with the medical department of the Homefront command. Data collection and analysis were done by the Trauma Branch of the Medical corp. RESULTS: 339 soldiers were injured, among them were 10 fatalities. Five hospitals received casualties, although the 2 regional hospitals received 84% of the primary evacuation load. The majority of urgently injured soldiers (90%) were evacuated by air, as opposed to 59% of non-urgently injured soldiers. CONCLUSIONS: In a cross border setting, airlifting the urgent casualties to farther away level I trauma centers provides appropriate care for them, while not crossing the "surge capacity" line for the near-by medical centers.

A retrospective study of the eligibility for tonsillectomy.

BACKGROUND: The criteria for tonsillectomy for recurrent tonsillitis were established by prospective studies in the pediatric population and are applied to adults as well. No studies have been conducted to assess whether these guidelines are followed. OBJECTIVES: To examine the eligibility for tonsillectomy of tonsillectomized patients who were referred because of recurrent acute tonsillitis. METHODS: A retrospective case series in an ambulatory military otolaryngology clinic was conducted, and the medical records of 44 tonsillectomized patients who suffered from throat infections during the year before surgery were analyzed. The number of tonsillar infections that met the referral criteria was counted. RESULTS: The average number of throat infections that met the referral criteria was 1.89 per year. The average number of visits to the clinic due to upper respiratory tract infection was 12.92 (range 2-36) per year. The average number of visits for any cause was 45.13 (range 6-64) per year. One patient with eight documented throat infections met the criterion of more than six infections in the last year. CONCLUSION: Although the referral criteria were not strictly met, we speculate that surgery was probably beneficial. This study shows that the indications for tonsillectomy referral are not strictly followed, and that new criteria for referral of adults for tonsillectomy need to be established.

Wireless capsule endoscopy in Israeli Defense Force: two years of experience.

OBJECTIVES: Evaluate outcome and diagnostic yield of capsule endoscopy (CE) in soldiers with suspected small bowel disease, in comparison to traditional diagnostic procedures. METHODS: 27 consecutive soldiers who underwent CE between June 2002 and February 2004 were enrolled. Results of CE were compared to standard techniques. RESULTS: CE was normal in 16 patients (59.3%). Findings could not explain any signs or symptoms were observed in 11.1%. Definite diagnosis of Crohn's disease was obtained in 11.1%. Patients (62.5%) with a triad of symptoms (abdominal pain, changed bowel habits, and gastrointestinal bleeding) versus 15.8% without that triad, had either diagnostic or suspicious CE (p = 0.015). Diagnostic yield of CE was higher in gastrointestinal bleeding (25%) in comparison to suspected Crohn's disease (15.8%). Three out of 6 patients (50%) with suggestive findings of Crohn's disease in the preliminary workup were diagnosed as definite Crohn's by capsule endoscopy. CE allowed the physician to conclude workup in 71% patients. CONCLUSION: CE should be used when obscure gastrointestinal bleeding or Crohn's disease is suspected without a conclusive diagnosis. Furthermore, when a triad of symptoms exists CE should be considered as first line examination.

A Novel Device for the Evacuation of Cerumen.

OBJECTIVES: The aim of this study was to assess a new device designed to safely remove cerumen from the external auditory canal in an office setting with minimal training. METHODS: The research was conducted in the Department of Otolaryngology at Kaplan Medical Center in Israel. Patients with cerumen were treated with the device. Efficacy, safety, and pain were evaluated using scales developed for this experiment. The cerumen obstruction scale (0-5) was assessed before and after the procedure. Improvement by 2 or more grades was considered to indicate at successful procedure. RESULTS: Fifty-nine ears in 46 patients were treated. Seventeen patients (37%) had recurrent cerumen impaction, and 14 (30.4%) used cotton swabs frequently. Fifty-two ears (88%) had hard cerumen. The procedure was successful in 51 ears (86.4%). In 48 ears (81%) there was no pain or mild pain, and in 11 ears (19%), the patient reported the procedure to be uncomfortable. Seven patients (15.2%) asked to abort the procedure because of discomfort or pain. In 39 ears (66%), the cerumen was evacuated easily. Inspection after the procedure revealed no injury in 56 ears (95%). Three ears (5%) had mild irritation of the ear canal, and none had injury to the tympanic membrane. Median length of the procedure was 30 ± 42.1 seconds (range, 2-240 seconds). The median number of insertions of the device in 1 procedure was 2 (range 1-7; SD, 1.3). CONCLUSIONS: The tested device is an effective and safe device for the evacuation of cerumen. It can be used by general practitioners, pediatricians, and audiologists.

Management of Acute Mastoiditis With Immediate Needle Aspiration for Subperiosteal Abscess.

OBJECTIVES: The management of children with acute mastoiditis (AM) is still debated. Some advocate computed tomography (CT) and cortical mastoidectomy (CM) for all cases while others favor a more conservative management. This study assesses the safety and outcome of a conservative management scheme, with immediate myringotomy and postauricular needle aspiration (PANA) of a subperiosteal abscess (SPA). METHODS: A retrospective cohort of children with AM younger than 12 years admitted to our institute between 1999 and 2017. Data collection includes patient characteristics, signs and symptoms, physical examination, laboratory tests, treatment regime, imaging findings, and long-term outcomes. RESULTS: The study included 283 children. Ninety-eight children (34.6%) had a suspected SPA on admission and underwent a trial of immediate PANA, and 56.1% (55 cases) were positive. Of these 55, 83.6% (46) did not require CM. Twenty-four additional children had an SPA, proven by CT or during surgery, bringing the total SPA cases to 79 (27.9%). Of all children with proven SPA, 70.9% (56) did not require CM, with the practiced conservative management sufficing. Intracranial complication rates were 4.9% (14) and 8.8% (25) underwent CM. Long-term follow-up was available for 250 children. One child had hearing loss with a bilateral mixed hearing loss (50 decibels). There were no cases of neurological sequela. CONCLUSIONS: Conservative management of AM, involving prompt myringotomy for all patients and PANA for SPA, is safe and effective, and reduces the need for CT and CM. Conservative management obviates unnecessary radiation, general anesthesia, and surgery, without increasing the risk of immediate or long-term complications.

Hemilaryngeal flap for hypopharyngeal reconstruction in pyriform sinus carcinoma.

CONCLUSION: The hemilaryngeal flap is a technique for hypopharyngeal reconstruction with the use of adjacent uninvolved tissue. The technique's advantages are that it is technically simpler than other surgical techniques for hypopharyngeal reconstruction, and involves no donor site morbidity. Its disadvantages are that it only can be employed in tumors which are confined to one side of the hemilarynx, and also there is always potential for skip lesions and incomplete resection. OBJECTIVE: To determine the indications, oncologic considerations, complication rate and survival of the surgical technique. MATERIALS AND METHODS: A meta-analysis of the available literature using the Medline database. RESULTS: There are 86 reported cases. The surgical technique was used only when one side of the hypopharynx was spared. Pharyngocutaneous fistulae developed in 16 patients (19%) and 2 patients developed pharyngeal stenosis. The technique was employed with advanced squamous cell carcinoma of the hypopharynx and the survival rates are similar to those reported when other reconstruction techniques are used.

Evolving resistant pseudomonas to ciprofloxacin in malignant otitis externa.

OBJECTIVE: To determine whether there has been an increase in ciprofloxacin-resistant pseudomonas malignant otitis externa, and if this has increased the morbidity of the disease. STUDY DESIGN: Retrospective. SETTING: Tertiary referral center. PATIENTS: Twenty-eight patients over 13 years. RESULTS: The records of a total of 28 patients who were admitted between 1988 and 2001 with the diagnosis of malignant otitis externa were reviewed. Seven patients had ciprofloxacin-resistant pseudomonas on their hospital culture and sensitivity test. Five of the 7 resistant cases appeared in the last 3 years, as opposed to 2 of the 7 who appeared in the 10 years before that period. In our series, there is a significant trend developing over time of pseudomonas resistant to treatment with ciprofloxacin. No increased morbidity or mortality was found in the ciprofloxacin-resistant pseudomonas group compared with the remaining patients who were sensitive to ciprofloxacin. CONCLUSIONS: In our series, resistance to ciprofloxacin in patients with malignant otitis externa is increasing over time. This may have an impact on the relatively successful outpatient treatment of these patients in the past decade. A return to inpatient or outpatient intravenous treatment with third-generation cephalosporins/antipseudomonal penicillins and more frequent debridement will be required in these patients.

Removal of sinonasal tumors by the endonasal endoscopic approach.

BACKGROUND: The external approach is the golden standard for sinonasal tumor removal but is associated with several side effects, including facial scars, intracranial and extracranial complications, a long hospitalization period and high costs. Endoscopic sinus surgery enables resection of benign and selected malignant sinonasal tumors and has the advantages of no facial scars, better functional and structural preservation of the sinonasal complex, minimal trauma to surrounding tissue, a shorter hospitalization stay and lower costs. OBJECTIVES: To evaluate the advantages and limitations of endoscopic resection of benign and malignant sinonasal tumors, their recurrence and complication rates. METHODS: The medical and radiology records of 56 patients who underwent endonasal endoscopic resection of benign and malignant sinonasal tumors between 1996 and 2003 were retrospectively reviewed. Tumors located in the center of the nose and sinuses were endoscopically resected. RESULTS: Six cases of malignant tumor and 50 cases of benign tumor underwent resection by ESS. One of the patients with malignant tumor died, the remainder showing no evidence of disease on follow-up of 3-60 months (mean 26.8 months). Inverted papilloma was the most common benign tumor (40 patients). Seven patients (18%) had recurrence followed by endonasal resection. No major complications were recorded. Hospitalization stay was 2-7 days (mean 3.6 days). CONCLUSIONS: Endoscopic resection of benign sinonasal tumors that are centrally located in the nose and sinuses should be considered before the external approach is used. In very carefully selected cases of malignant tumors ESS is oncologically acceptable, but more experience is needed for discerning the indications for endoscopic resection of malignant tumors. The complication rate for endoscopic resection is low, there are no facial scars, hospitalization stay is short, and costs are low.

Prehospital intubation success rates among Israel Defense Forces providers: epidemiologic analysis and effect on doctrine.

BACKGROUND: Advanced airway management is composed of a set of vital yet potentially difficult skills for the prehospital provider, with widely different clinical guidelines. In the military setting, there are few data available to inform guideline development. We reevaluated our advanced airway protocol in light of our registry data to determine if there were a preferred maximum number of endotracheal intubation (ETI) attempts; our success with cricothyroidotomy (CRIC) as a backup procedure; and whether there were cases where advanced airway interventions should possibly be avoided. METHODS: This is a descriptive, registry-based study conducted using records of the Israel Defense Forces Trauma Registry at the research section of the Trauma and Combat Medicine Branch, Surgeon General's Headquarters. We included all casualties for whom ETI was the initial advanced airway maneuver, and the number of ETI attempts was known. Descriptive statistics were used. RESULTS: Of 5,553 casualties in the Israel Defense Forces Trauma Registry, 406 (7.3%) met the inclusion criteria. Successful ETI was performed in 317 casualties (78%) after any number of ETI attempts; an additional 46 (11%) underwent CRIC, and 43 (11%) had advanced airway efforts discontinued. ETI was successful in 45%, 36%, and 31% of the first, second, and third attempts, respectively, with an average of 28% success over all subsequent attempts. CRIC was successful in 43 (93%) of 46 casualties in whom it was attempted. Of the 43 casualties in whom advanced airway efforts were discontinued, 29 (67%) survived to hospital discharge. CONCLUSION: After the first ETI attempt, success with subsequent attempts tended to fall, with minimal improvement in overall ETI success seen after the third attempt. Because CRIC exhibited excellent success as a backup airway modality, we advocate controlling the airway with CRIC if ETI efforts have failed after two or three attempts. We recommend that providers reevaluate whether definitive airway control is truly necessary before each attempt to control the airway.

Intratympanic gentamicin injections for the treatment of Ménière's disease.

OBJECTIVE: To assess the success rate and complications of treatment with injections of intratympanic gentamicin to the middle ear of patients with Ménière's disease. STUDY DESIGN: Case series with chart review. SETTING: A tertiary otologic private ENT clinic. SUBJECTS AND METHODS: Patients with Ménière's disease, who had not responded to medical treatment. Included in the sample were patients with Ménière's disease who had been treated with injections of gentamicin into the middle ear. After each gentamicin application, patients were monitored for their symptoms and hearing. If symptoms persisted, they received another intratympanic injection of gentamicin. This method is referred to as the variable titration method. A retrospective chart review was performed, and questionnaires were used to assess hearing, functional status, tinnitus, ear fullness sensation, and the control of vertigo attacks in response to treatment. RESULTS: Nineteen patients were sampled. Eighteen patients (94%) had complete or substantial control of vertigo. Five patients (26%) had worse hearing results on their post-treatment audiogram, averaging 13 dB hearing loss (range, 5-25 dB). In response to the questionnaires, all patients reported a significant improvement in the quality of life after treatment. CONCLUSION: The treatment was found to be highly effective. The variable titration method of injection prevents unnecessary injections for patients whose symptoms have already subsided.